McKenzie Towne Continuing Care Centre (MTCC)

McKenzie Towne Continuing Care Centre (MTCC)
Update January 22, 2014
Background:
This review is a result of a concern brought forward as a result of PPIC report.
The structure of the review will reflect past AHS reviews in continuing care owned and contracted environments. The action plan will have the following structure:
• Identified actions
• Expected targets
• Anticipated outcomes
• Accountabilities
Action Items
Completed
In Progress
Delayed
Upon initial discussions the following themes were identified:
1. Requirement for oversight related to quality of care and resident safety at Revera McKenzie Towne Continuing Care (MTCC) facility.
2. Requirement of current audit for standards and compliance at MTCC.
3. Agreement of response to Protection for Persons in Care (PPC) letter by December 31, 2013.
4. Confirmation of status and follow up of patient complaint logs for all Revera continuing care facilities in Alberta.
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McKenzie Towne Continuing Care Centre (MTCC)
Update January 22, 2014
1
1.1
Coordination of Action Plan
Action Item
Target
Date
Draft the action plan.
Dec 4,
2013
1,2
Notify and update
CEO Office.
1.3
Develop / submit
Final Summary of
quality assurance
activities during the
oversight period.
2
2.1
2.2
Dec 4,
2013
and then
weekly
starting
Dec 9,
2013
Review
@ Jan
31, 2014
Required Outcome
Responsible Party
Progress to date
Approved plan to track
actions of Quality
Assurance Plan.
Executive Director,
Integrated Seniors
Health, Calgary Zone
Draft action plan in place. Target
dates may change with
circumstances and additional
actions may be added.
CEO Office informed of
Quality Assurance Plan.
Senior Vice President,
Calgary Zone
Weekly updates.
Final documented
summary of
accomplishments of
Quality Assurance Plan.
Executive Director,
Integrated Seniors
Health, Calgary Zone
.
Responsible Party
Progress To Date
Executive Director,
Integrated Seniors
Health, Calgary Zone
AHS Lead assigned and will be
on site Dec 4, 2013.
Theme 1 - Oversight regarding quality and safety issues
Action Item
Target
Required Outcome
Date
Assign AHS individual
Dec 3,
Confidence and
to oversee the related 2013
agreement that quality
quality activities.
care is being provided at
MTCC and issues have
been fully addressed.
Outline expectation in
Dec 4,
Expectations are clear
letter of assignment
2013
regarding the onsite
to the identified AHS
oversight.
Lead.
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Letter sent.
Date
Completed
Dec 4, 2013
Actual Outcome
Ongoing
Weekly update
process in place.
Plan drafted and
submitted.
Date
Completed
Dec 3, 2013
Actual Outcome
Dec 4, 2013
AHS staff member
reports expectations
are clear.
On site AHS staff in
place.
McKenzie Towne Continuing Care Centre (MTCC)
Update January 22, 2014
2
2.3
2.4
Theme 1 - Oversight regarding quality and safety issues
Action Item
Target
Required Outcome
Date
Hold weekly meetings Weekly
All parties informed of
with AHS Lead and
starting
progress related to this
appropriate AHS
Dec 9,
request.
stakeholders.
2013
Weekly reporting to the
Submit written report
Senior Vice President,
weekly to Senior Vice
with escalation as
President, Calgary
required.
Zone
Meet weekly (at a
Weekly
Quality issues are
minimum) with MTCC
starting
identified and acted on in
leadership to monitor
Dec 9,
a timely fashion.
progress of oversight
2013
activities and address
any newly identified
safety issues (may
include additional
focused review).
Responsible Party
Progress To Date
Executive Director,
Integrated Seniors
Health, Calgary Zone
Scheduled and in progress.
AHS Lead (assigned
onsite at MTCC)
Wound care rounds will be
weekly or every two weeks,
depending on client complexity.
Scheduled and in progress.
AHS lead attending clinical
huddles with professional staff.
Huddles occur daily at 07:15
and 15:15. Daily participation
until January 31, 2014,
weekly participation until
February 28, 2014; Biweekly presence until March
31, 2013.
Issues arising:
Reporting and Learning System
(RLS) investigation completed
at SHC on resident transfer
related to removal of a
catheter. The incident has
resulted in a staff reminder
to read doctors orders and
care plan before action –
staff meeting on January 24,
2013.
Nasopharyngeal swab testing on
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Date
Completed
Ongoing
Weekly reports
submitted Dec
12, 19, 27,
2013; Jan 3, 8,
15, 22, 2014.
Ongoing.
Actual Outcome
McKenzie Towne Continuing Care Centre (MTCC)
Update January 22, 2014
2
Theme 1 - Oversight regarding quality and safety issues
Action Item
Target
Required Outcome
Responsible Party
Date
Progress To Date
Date
Completed
Actual Outcome
Dec.27, 2013
Patient concern
reports and Incident
reports found to be
within normal range
for continuing care.
Will continue to
monitor based
through normal
process.
three residents. All results
negative. All improving.
AHS has started Quality
Assurance Review (QAR). AHS
QHI leading the review;
interviews have been
scheduled.
Site Skin and Wound Care
strategies were reviewed on
January 20, 2014.
2.5
Review recent Quality
Indicator reports from
MTCC e.g.
- PPIC reports
- Patient Concerns
reports
- Reportable
Incident reports
Dec 16,
2013
Recent history of quality
issues are identified for
potential areas of
focused review.
AHS Lead (assigned
onsite at MTCC)
2.6
Conduct a site review
of skin and wound
care and report on
same to AHS Lead.
Dec 13,
2013
Any deficiencies are
identified.
Integrated Supportive
and Facility Living
(ISFL) SWAT Lead
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AHS Skin and Wound
consultant will visit the site
weekly until the end of
March 2014, at which time
the process will be reviewed.
Complete
AHS Lead assigned and was on
site December 4 & 5, 2013.
Wound review is complete.
Audit reports contain
recommendations and actions.
Dec. 6, 2013
Dec. 12, 2013
McKenzie Towne Continuing Care Centre (MTCC)
Update January 22, 2014
2
Theme 1 - Oversight regarding quality and safety issues
Action Item
Target
Required Outcome
Responsible Party
Date
Progress To Date
Date
Completed
Actual Outcome
AHS lead met with operator – to
provide recommendations on
December 12, 2013.
AHS recommendations have
been forwarded and AHS will
reassess weekly until issues
resolved.
Ongoing weekly
assessments.
Revera wound care pathways
are being followed by MTCC
staff.
2.7
Identify needed skin
and wound care
improvements to
MTCC and monitor
implementation.
Dec 6,
2103
2.8
Conduct a quality
review of the Resident
Assessment
Instrument (RAI)
process and ensure
RAI outputs are being
integrated in care
planning and care
delivery.
Jan 13
2014
Standards are met
relative to skin and
wound care. CCHSS
standards state a policy
must be in place to
address skin and wound
care.
RAI is being used
appropriately for clinical
care and funding.
AHS Lead (assigned
onsite at MTCC) / ISFL
SWAT Lead
AHS Lead (assigned
onsite at MTCC)
Pixilaire computer tracking
system will be implemented.
Ensure the policy is in place as
per CCHSS standards
requirements –complete
Ideal number to review is 10%
(15 charts at McKenzie Towne).
Need to link the RAI
assessments outcomes with the
care plans.
Dec. 6, 2013
Dec. 19, 2013
completion of
RAI chart
review.
MDS coordinator is on site and
supporting staff.
January 13,
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Policy in place
McKenzie Towne Continuing Care Centre (MTCC)
Update January 22, 2014
2
Theme 1 - Oversight regarding quality and safety issues
Action Item
Target
Required Outcome
Responsible Party
Date
Progress To Date
Draft RAI review report
completed and submitted to
AHS Seniors Health.
Report will be circulated to the
operator and Calgary Zone
operations for review and action
on January 17, 2014.
2.9
Develop plan to
provide / reinforce
staff awareness and
education re RAI
assessment and
subsequent nursing
process.
Dec. 20,
2013.
Staff uses the RAI output
information to inform
client care and client
needs are being met
though improved care
plans.
AHS Lead (assigned
onsite at MTCC)
Results – coding logic is
good. Outstanding issue is
the care plan follow up. This
action is complete and will
be followed up as outlined in
2.9.
All relevant staff are up to date
with Assessment and
Intelligence Systems (AIS)
competencies.
AHS will support oversight of
staff education until January 31,
2014. MTCC's readiness to
assume this responsibility was
evaluated on January 20, 2014.
Care Plan review meeting on
December 19, 2013. Updates
will be made to electronic and
printed versions, with AHS lead
input. Target is to complete all
updates by the end of March
2014. 50 complete by the end
of January 2014 and an
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Date
Completed
2014.
Report
received
January 17,
2014.
Dec. 18, 2013.
Actual Outcome
McKenzie Towne Continuing Care Centre (MTCC)
Update January 22, 2014
2
Theme 1 - Oversight regarding quality and safety issues
Action Item
Target
Required Outcome
Responsible Party
Date
Progress To Date
additional 100 by March 31,
2014.
Checkpoint meeting between
AHS and Revera MTCC on
January 20, 2014. Of the ten
required actions from AHS
audit, three are complete.
Five to be complete by
January 31, 2014. Two
actions – care plans and
wound care - to be complete
by March 31, 2014.
AHS will continue onsite
presence once a week to
February 28, 2014, once
every 2 weeks until March
31, 2014. AHS Care Manager
and Revera MDS worker are
engaged to support
sustainability.
AHS Wound Care specialist
will visit MTCC weekly.
Anticipating sign off on
March 31, 2014.
Recommended future AHS
CCHSS Audit to be scheduled
within 6-8 months.
Revera has an education
plan for resistive behavior –
details to be provided by end
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Date
Completed
Actual Outcome
McKenzie Towne Continuing Care Centre (MTCC)
Update January 22, 2014
2
2.10
2.11
Theme 1 - Oversight regarding quality and safety issues
Action Item
Target
Required Outcome
Responsible Party
Date
Review and develop a
site process for
ongoing engagement
with and support for
families.
Determine when
“quality of care issues
have been fully
addressed” at the site.
Jan 31,
2014
Families are engaged
with the site and have
input to the developed
plan of care.
AHS Lead (assigned
onsite at MTCC)
Review
@ Jan
31, 2014
AHS sign off that quality
care issues have been
addressed;
discontinuation of the
required onsite presence
at MTCC.
Executive Director,
Integrated Seniors
Health, Calgary Zone
Progress To Date
Date
Completed
Actual Outcome
of January2014.
Resident family Council process
for patient logs is in place.
Dec. 5, 2013
This requirement
was considered to
be met in the audit.
Complete.
PPIC response – complete
Dec. 27,2013
Recommendations responded to
in AHS and AH audits.
complete.
Sign off from AHS wound
specialist required. Full sign off
will require Calgary Zone
Operations and AHS Executive
approval.
Dec. 19, 2013
January 20, 2014 meeting to
discuss ongoing sustainability
and sign off process and
approach. AHS onsite presence
anticipated until January 31,
2014.
3
3.1
See plan outline in
section2.9
Theme 2 - Audit for compliance to Continuing Care Health Service Standards (CCHSS) required update.
Action Item
Target
Required Outcome
Responsible Party
Progress to Date
Date
Conduct AHS audit to
Dec 4 AHS audit complete.
AHS Calgary Zone
AHS Calgary Zone Team
CCHSS at MTCC.
5, 2013
Standards and
scheduled to be on site Dec 4,
Compliance Unit.
2013.
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Date
Completed
Dec 4, 2013
Outcome
Complete.
McKenzie Towne Continuing Care Centre (MTCC)
Update January 22, 2014
2
3.2
3.3
Theme 1 - Oversight regarding quality and safety issues
Action Item
Target
Required Outcome
Date
Complete AHS Audit
Dec 12,
Audit Report and
Report.
2013
recommendations
forwarded to MTCC for
review and action.
Alberta Health
Dec 5,
Alberta Health audit
conducts audit to
2013
complete.
CCHSS at MTCC.
Progress To Date
Date
Completed
Dec 10, 2013
Actual Outcome
AHS Calgary Zone
Standards and
Compliance Unit.
Complete.
Alberta Health Audit
Team.
Alberta Health Audit scheduled
for Dec 5, 2013.
Dec 5, 2013
Complete.
Alberta Health Audit
Team.
Complete.
Dec 6, 2013
Complete.
AHS Lead and AHS
Calgary Zone
Standards and
Compliance Unit.
MTCC
Reviewed previous CCHSS audit.
Dec 11, 2013
Complete.
Dec 2011 Medication issues
have been resolved. The care
plan issue is unresolved from
2011.
Dec 11, 2013
Unresolved care
planning issue
becomes part of
current audit
action plan.
AHS Calgary Zone
Standards and
Compliance Unit and
ISFL, Calgary Zone
See plan outlined in 2.9.
3.4
Alberta Health
completes audit
Report.
Dec 12,
2013
3.5
Review previous
CCHSS audit results
and related
improvement actions.
Develop action plan
for any non-compliant
CCHSS Standards.
Dec 13,
2013
Dec 19,
2013
Any deficiencies
identified in previous
audits will be addressed.
3.7
Review action plan
and monitor
completion of actions
related to current
CCHSS improvement
plan.
Jan 31,
2014
CCHSS will be met.
4
Theme 3 Response to Protection of Persons (PPIC) review
Action Item
Target
Required Outcome
Date
3.6
Page | 9
Audit Report and
recommendations
forwarded to MTCC for
review and action.
Confirmation that and
improvement actions
have been implemented.
Responsible Party
Responsible
Party
Progress to Date
Date
Completed
Complete.
Outcome
McKenzie Towne Continuing Care Centre (MTCC)
Update January 22, 2014
4
4.1
Theme 3 Response to Protection of Persons (PPIC) review
Action Item
Target
Required Outcome
Date
Review documented
Dec 16,
Confirmation that actions completed tochronology of events,
2013
date have been implemented
planned actions to(evidence).
date, and actions
completed to-date.
Responsible
Party
AHS Lead
(assigned onsite
at MTCC)
Progress to Date
MTCC will send the
draft response to
Revera legal, then
distributed.
4.2
Review the
recommended actions
and implementation
plan and timelines.
Jan 6,
2014
Appropriate recommendations made
and implementation plan in place.
AHS Lead
(assigned onsite
at MTCC)
4.3
Monitor completion of
action items.
Submit report to PPIC
(with copy to AHS) on
progress and
completion of
improvement actions.
Jan 31,
2014
Jan 31,
2014
Conditions for future quality care are in
place.
Final documented summary of
completed actions of response plan.
AHS Lead
Response sent and
received. AHS
responded to the
response document –
sent to B. Huband
Dec. 31, 2013.
AHS to develop a
formal referral process
for continuing care
based on the
suggestion in
response to PPIC from
MTCC - Complete
Complete
MTCC
Complete
4.4
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Date
Completed
Dec. 27, 2013
January 7,
2014
January 30,
2014
January 30,
2014
Outcome
McKenzie Towne Continuing Care Centre (MTCC)
Update January 22, 2014
5
5.1
Theme 4: Confirmation of patient concerns log for all Revera sites
Action Item
Target
Date
Required Outcome
Responsible
Party
Progress to Date
Review of patient
concern logs for all
Revera continuing care
sites in Alberta.
Dec 31,
2013
Confidence that process is in place and
patient concerns are being addressed in a
timely manner within an acceptable time
frame of 30 days.
Vice President,
Primary and
Community Care
The Revera site logs have
been received and
reviewed. AHS can
confirm that all were
closed within a
reasonable timeframe.
Revera Designated
Supportive Living (DSL)
Calgary:
• Chateau Renoir (no
AHS contract)
• McKenzie Towne
• Scenic Acres
• The Edgemont
• The Heartland
(Okotoks)
Edmonton
• Riverbend
• The Churchill
Medicine Hat
• Meadowlands
Revera Long Term Care
(LTC):
Calgary
• Bow-Crest
• McKenzie Towne
• Mount Royal
Edmonton
• Jasper Place
• Miller Crossing
• South Terrace
Page | 11
AHS, President and
CEO’s Office
Date
Completed
AHS Patient Concerns
logs and AHS Reportable
Incidents have been
reviewed. AHS can
confirm that all were
closed within a
reasonable timeframe.
An additional review of
all unwitnessed falls is
being undertaken to
assess the root cause.
Received Falls protocol
from MTCC. Fully
implemented.
December 27,
2013
Outcome